The microcephaly diagnosis was considered one of the main mothers’ stressors, and several strategies had been used to face the news, especially those linked to the coping family, such as searching for information – including asking others (n = 8) and searching for information on the internet (n = 7) – as can be seen in the following report:

I went to this appointment with the doctor; when I got there I tried to find out. She said very little, that it was microcephaly, which she didn’t even know, because it was right at the beginning, right? And in that, information was generated. I tried to find out with other mothers, and in the Whatsapp groups, computer

This family’s strategy demonstrates a regulation action associated with the basic need for competence, in which individuals perceive the stressful situation as a challenge to their context and try to learn more about the situation to resolve it or mitigate its effects (Ramos et al., 2015). Considering the little scientific information available about microcephaly and CZVS at the time of children’s birth, it is understandable why strategies belonging to the information search category were so recurrent among mothers.

Faced with the diagnostic stressor, although less frequent, other important adaptive strategies were also identified, linked to the “Accommodation” coping family, such as acceptance (n = 5), and “Search for support” through the search for comfort (n = 4). Although both families relate to the view of the stressful situation as a challenge, the “Accommodation” family refers to a challenge of the self and its strategies imply active attempts to modify the view of the stressful situation, considering the basic need for autonomy (Ramos et al., 2015). The search for support, on the other hand, is linked to the need for a relationship and portrays the individual’s attempt to use available social resources to deal with the stressor (Ramos et al., 2015).

In a less adaptive scope, strategies linked to the coping family “Helplessness” were used, including confusion (n = 4), cognitive exhaustion (n = 2), passivity (n = 2), and emotional exhaustion (n = 1), as pointed out in the following statements: “At the time (of the diagnosis) I got totally lost; I didn’t even look for information like that... I was totally lost; they didn’t give me any information at all” (Rosa, 31 years old).

Rumination (n = 9), belonging to the “Submission” coping family, was a strategy used by some mothers to face the diagnosis given. Some mothers, for example, questioned the reason for the situation: “I put everything on my mind a lot: “will she walk?”, “will she talk?”... And today I learned to conform, be it that God’s will is done, if it has to be, it will be, if not… (Camelia, 26 years old). The use of this maladaptive strategy occurs in the face of the impact of the diagnosis given, being abandoned over time, which characterizes a process of assimilation.

The strategies belonging to the “Helplessness” family are associated with a view of the stressor as a threat to the self, specifically with regard to the need for competence. In this case, strategies linked to this family demonstrate the mothers’ feeling of helplessness in the face of the diagnosis. The “Submission” family, in turn, also concerns a threat to the self, but in terms of the need for autonomy. In this connection, maternal strategies showed a passive and repetitive focus on the negative aspects of the diagnosis.

Thus, the impact of the diagnosis initially generated intense feelings of fear and helplessness, common to receiving diagnoses of a child’s malformations, intellectual disabilities, and developmental disabilities in general, according to the literature on the subject (Coletto & Câmara, 2009; Lai et al., 2015; Li-Tsang et al., 2001; Santos & Pereira-Martins, 2016). At this time, the diagnostic stressor was perceived as a threat to the basic need for competence (Vasconcelos & Nascimento, 2016), being associated with the shock and feeling of helplessness caused by the news in the family system, since mothers expect to have a healthy child. This is also evidenced by the use of strategies linked to the family of “Helplessness”, demonstrating that mothers, after the diagnosis, did not feel capable of taking care of the child. Despite this, over time, as the participants reported, these maladaptive strategies are abandoned as the mother adjusts to the situation and learns to deal with it, replacing them with adaptive strategies, as is the case of the strategy “ask others” linked to the coping family “Search for information”.

The search for information took place, above all, through the exchange of experiences with other mothers who were facing the same situation. This signals a new understanding of the diagnostic stressor, now seen as a challenge that drives mothers to seek ways to understand and learn to deal with a CZVS child. The exchange of experiences with peers was pointed out by Barros et al. (2017) as one of the main coping strategies used to deal with the daily care of their CZVS children. Obtaining more information from other women who are in the same situation helps develop self-confidence and contributes to the process of building the meaning of this new stressful event thus demonstrating the importance of the interpersonal dimension for the coping process (Didericksen et al., 2018).

The mothers’ routine, which generally involved the CZVS child’s daily care, was characterized as a stressor for the participants. To deal with daily life, coping behaviors of the “Problem-solving” family were reported, such as instrumental actions (n = 9) and planning strategies (n = 3), which shows that mothers were looking for active ways to deal with the stressor, according to the following comments: “take her to the physio, you know, which is more important, to the doctor... take care of her” (Violeta, 25 years old).

Coping strategies associated with the coping family “Search for support” were also observed, with the use of instrumental help strategies (n = 3) and contact search (n = 1). “When I’m at home, her father always helps me with him, for me, like, cleaning the house, washing clothes, things like that... And my mother always stays with him so I can take care of my things, my sister... stays with him.” (Rosa, 31 years old). Strategies associated with the coping family were also identified such as the search for information by asking other people (n = 5). However, the presence of strategies associated with the “Helplessness” (n = 4) and “Escape” (n = 2) families indicated difficulties in dealing with the childcare routine, evidencing the perception of threats from this stressor both to the self and the context.

Therefore, the data show the use, for the most part, of adaptive strategies to face the childcare routine, revealing an active positioning of mothers in this context, mainly related to the use of strategies linked to the coping family “Problem-Solving”. In this connection, mothers felt competent to solve the care demands, even though they used coping strategies “Search for support”, to trigger their support network, which, in most cases, was formed by the spouse or by the extended family, in order to meet her basic relationship needs.

Given the intensity of the childcare routine, mothers sometimes ended up assuming this role in full, generating overload and stress. This fact can be understood from a sociocultural perspective that also associates motherhood with selflessness and sacrifice. In a study with mothers of children with CZVS, Mendes et al. (2019) also found that women played a key role in child care, being, in most cases, the only caregiver. Assuming this role usually made it impossible for them to carry out a work activity, continue their studies, or even maintain bonds of friendship due to the intense child-caring routine, a common aspect in connection with disabilities (Reis & Paula, 2018). In our study, however, despite the mother being at the core of child care, this task was sometimes shared with the partner and other family members.

The use of family “Problem solving” coping strategies was frequently identified in the coping process with the treatment and development of the child, especially the instrumental action strategies (n = 13) and planning strategies (n = 1) observed that include the behaviors of stimulating the child, seeking professional help, seeking health treatments for the child, among others. These data indicate an active coping with the stressor, thus increasing the feeling of competence and favoring the adoption of new actions by mothers (Ramos et al., 2015).

The second most used strategy by mothers in the face of this stressor was associated with the “Accommodation” family, with the use of the cognitive restructuring strategy (n = 9), which implies a process of re-signifying the stressor in connection with the psychological need for autonomy. In this connection, the use of the coping behavior “visualizing the child’s progress”, which appears in the comments of seven of the participants, demonstrates the search to modify perceptions and feelings about the stressor: “I understand the development well, right? It’s going well, only if he were calmer it would be better, well, learn faster, but he’s fine, he’s evolving” (Azaleia, 31 years old).

Regarding the child’s development, there are also reports of the use of maladaptive strategies linked to the “Helplessness” family, such as cognitive exhaustion (n = 5). In connection with the coping family “Escape”, the wishful thinking (n = 8) and mental withdrawal (n = 2) strategies were observed, as stated by one of the mothers: “I keep thinking if she hadn’t been born with a micro, she would be already... walking, at school... with a friend. Sometimes I... I feel sad for her... that you keep thinking... of her wanting to do something and not being able to” (Girassol, 28 years old).

The mother’s comments evidence the procedural character of coping. Initially, the coping strategy used was wishful thinking, through the expression of the desire for the child to develop and be a ‘normal’ child, fitting her idealization. Over time, however, there is an abandonment of this strategy in favor of acceptance, associated with the coping family “Accommodation”.

On the other hand, while mothers adapt to the treatment and development of the child and restructure themselves cognitively, some continue to use the wishful thinking strategy, believing that, with the therapies, children will achieve certain goals set by them, such as walking, talking, and develop as a “normal” child. In this connection, God appears as the one capable of changing their children’s condition, through a miracle, and such thoughts seem to drive mothers in the search for treatments for their children, averting their abandonment: “My expectation... I think he’s going to sit, I even think he’s going to walk, I don’t know... God knows, but... my expectation of his development is this, that he’ll be able to sit, crawl, walk” (Rosa, 31 years old).

In the Brazilian culture, especially in the Northeastern region, where the survey was carried out, there is a strong influence of religiosity in the population. Most participants (n = 9) declared to follow some religious guidelines, which probably influenced the use of religious/spiritual coping strategies. Although the CMT does not address religious coping as a specific category, theorists of this perspective postulate that religious/spiritual coping can facilitate problem-solving, help in seeking comfort, and prevent or alleviate negative emotional consequences in stressful situations (Foch et al., 2017), also allowing acceptance and giving meaning to the situation (Hatun et al., 2016). Thus, on the one hand, faith and hope keep the expectation of progression in the child’s development, but on the other hand, it can generate frustration if such expectations are not met (Santos & Pereira-Martins, 2016).

Access to health services was characterized as a stressor in view of the difficulties faced by mothers; it was mainly associated with transport to get to the health service and to return home. Many mothers go to Campina Grande for specialized care for their children, and even those who lived in that municipality do not have their own car to get there. In the Paraíba scenario, Barros et al. (2017) indicated the transport provided by the municipalities as being the greatest difficulty for mothers of CZVS children, which was also verified in this investigation. Another difficulty reported in the mothers’ statements was related to the long waiting time at the health institution.

The most used coping strategies were associated with the “Delegation” coping family, such as complaint (n = 9) and lamentation (n = 3); to the family “Helplessness”, as cognitive exhaustion (n = 2); “Opposition”, as the use of the strategy of blaming others (n = 2); and “Submission”, with rumination (n = 1). In the narratives about coping with this stressor, it was noticed that the mothers repeatedly resort to the complaint strategy, mainly in relation to the lack of specialized services in the municipality where they live and in relation to the non-fulfillment of their responsibilities on the part of the public authorities, as mentioned hereafter: “It’s an external treatment, it’s a better treatment that the municipality doesn’t have and they (Municipal Health Department) don’t even want to provide a car, we (mothers) feel very bad.”(Orquídea, 26 years old).

In this connection, complaints about the lack of specialized services in the municipality where they lived, the lack of adequate transport to travel to the health institution, and the perception of the lack of effective service from public policies generated feelings of exhaustion and impotence. Despite being classified as non-adaptive strategies, when considering the context, the failures of the country’s Public Health System are evident; the health system was unable to offer comprehensive care according to the needs of these mothers and their families. Given this scenario, although they acknowledge several difficulties in connection with access to health services, mothers feel gratified for being able to take their children to medical and therapeutic visits, doing the best they can for their children.

In general, the analysis of the coping strategies used by mothers who give birth to a child with CZVS shows that there is an increase in the family’s stress levels, with the direct caregiver usually being the most affected family member. In addition, the greater the child’s prejudice, the greater the care demands and, consequently, the greater the parents’ burden (Reis & Paula, 2018).

In this connection, when a child with CZVS is born, negative feelings are generated, first, because the child has a disability and, second, because it is a clinical condition whose consequences are still poorly known by mothers and even by science (Silva et al., 2016; Vicente et al., 2016). This factor, in addition to the severity of the syndrome, directly influences parents’ abilities to deal with the diagnosis (Gomes & Piccinini, 2010).

In this study, the adaptive strategies identified in the mothers’ statements were associated with the perception of stressors as challenges to the three basic needs proposed by the CMT. The diagnostic stressor, for example, challenged mothers’ competence and relationship needs more, and the most used strategies were context-oriented. On the other hand, in the stressor “Routine and Childcare”, challenges to the competence needs appear with greater incidence, revealing more strategies associated with the self. In the case of the stressor “Treatment and development of the child”, challenges to competence and autonomy and strategies associated with the self were highlighted.

The maladaptive strategies used by mothers were mainly associated with the perception of stressors as a threat to the basic needs of competence and autonomy. In other words, when mothers used such strategies, it signaled that, at that specific time, they had a perception of low self-efficacy to deal with the situation, either because they did not see possible alternatives to be taken in the face of the threats imposed by the CZVS, or because, although they envisaged alternatives, those alternatives were not available. This occurred, for example, when mothers identified the need for treatment for a particular type of problem resulting from the syndrome, but this treatment was not available or accessible through the municipal health network. The stressor “Access to health services” stands out, considering that, unlike the other stressors, it presented only maladaptive strategies aimed mainly at the self, being considered a threat to the three basic needs: autonomy, competence, and relationship.

Over time, however, about two or three years after the birth of their CZVS child, mothers begin to play a more active role, using mainly adaptive strategies associated with the search for family support. This observation demonstrates the basic role of other people’s support in caring for the child, and the importance of social support to these mothers, sympathizing with their feelings. In addition, the use of accommodation strategies, such as acceptance and cognitive restructuring, indicates that, over time, there is a mother’s acceptance regarding the situation of raising a child with health problems due to the Zika virus infection.

In this connection, religiosity emerges as a coping facilitating element, giving meaning to the experience of motherhood, mainly because it allows the use of metaphors for having a child with CZVS as something special and a mission (Pinheiro, 2018); this element has been identified in this survey’s participants’ statements. Coping strategies related to religiosity are often used by mothers and fathers of children with congenital malformations, including CZVS, as indicated in the literature (Félix & Farias, 2018; Mendes et al., 2019; Silva et al., 2016).